Blood culture utilization and impact of stewardship practices during a national blood culture bottle shortage at a cancer center

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Abstract
Formulating safe and effective diagnostic stewardship guidance for blood cultures in immunocompromised patients is challenging due to limited data and high risk of infectious complications. A 2024 global shortage in blood culture bottles (BD Diagnostics) necessitated the implementation of blood culture stewardship, including at our tertiary care cancer center. This was a retrospective pre-post intervention study of the effects of diagnostic stewardship at a stand-alone cancer center during a 5-month period of the 2024 blood culture bottle shortage compared to the same 5-month unaffected period in 2023. Interventions included discontinuation of an ordering set for persistent fever, modification of an ordering set for new fever to recommend two sets of blood cultures for initial workup, and issuing revised blood culture ordering guidance to providers, phlebotomists, and nurses with repeated educational efforts. Stewardship interventions led to decreased blood culture utilization by 36.3% (from 14,021 to 8,932), while the number of patients tested remained similar. Greatest reductions in utilization occurred in inpatient encounters and with follow-up blood cultures. There was a trend toward increasing blood culture positivity following intervention, excluding potential contaminants (7.1% vs 7.6%, P = 0.08). The frequency of sepsis-coded encounters and 30-day mortality rate were similar between the two time periods. No adverse outcomes related to blood culture stewardship were reported. A significant reduction in blood culture utilization is achievable in a high-complexity cancer patient population without negative clinical impact through limiting the number of initial blood cultures and eliminating pre-emptive ordering of blood culture orders for persistent fever. IMPORTANCE: Cancer and transplant patient populations are frequently excluded from experimental studies on decreasing blood culture utilization, but a recent global supply shortage in blood culture bottles provided a valuable opportunity to evaluate the effects of stewardship interventions on a large scale. This study, centered on a high-complexity cancer patient population, found that a significant 36.3% reduction in blood culture utilization was achievable, safe, and effective through multidisciplinary diagnostic stewardship efforts.

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